EVIDENCE-BASED MENTAL EVIDENCE-BASED MENTAL HEALTH PRACTICESHEALTH PRACTICES
Anthony F. Lehman, M.D., M.S.P.H.
Professor and Chair
Department of Psychiatry
University of Maryland
10 Leading Causes of Disability in 10 Leading Causes of Disability in the World (WHO, 1997)the World (WHO, 1997)
Unipolar Depression Iron-deficiency Anemia Falls Alcohol Use COPD Bipolar disorder Congenital anomalies Osteoarthritis Schizophrenia Obsessive-compulsive
disorder
10.7% 4.7 4.6 3.3 3.1 3.0 2.9 2.8 2.6 2.2
CHANGES IN PRIVATE HEALTH CHANGES IN PRIVATE HEALTH CARE EXPENDITURESCARE EXPENDITURES
1988-19971988-1997(HAY GROUP STUDY, 1998)(HAY GROUP STUDY, 1998)
Overall health care expenditures decreased by 7% between 1988-1997
Mental health care expenditures decreased by 54%
PORT ProcessPORT Process
Review literature regarding evidence for practice (efficacy)
Analyze data on variations in practice Develop outcomes information to examine
relationship of treatment and patient outcomes (effectiveness)
Develop treatment recommendations based on literature and outcome studies
Disseminate findings to change current practices
Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations
Recommendation 1: Antipsychotic medications, other than clozapine, should be used as the first-line treatment to reduce psychotic symptoms for persons experiencing an acute symptom episode of schizophrenia.
Conventional Antipsychotics: Conventional Antipsychotics: Efficacy-Effectiveness GapEfficacy-Effectiveness Gap
Annual Relapse Rates- Placebo: 70%- Efficacy in clinical trails: 23%- Effectiveness in practice: 50%
Factors Affecting Efficacy-Effectiveness Gap
- Patient heterogeneity- Prescribing practices- Noncompliance
(from Kissling, 1992) _________________
Schizophrenia PORT
Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations
Recommendation 2: The dosage of antipsychotic medication for an acute symptom episode should be in the range of 300-1000 chlorpromazine (CPZ) equivalents per day for a minimum of 6 weeks. Reasons for dosages outside of this range should be justified. The minimum effective dose should be used.
0
10
20
30
40
50
60
%
Improvement
(2-4 h)
Dose, mg (Fluphenazine)
Baldessarini et al. (1988), Arch Gen Psych 45:79-91
Effective Dosage Range: Acute Treatment
1 2 3 5 10 20 30 50
Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations
Recommendation 9: The maintenance dosage should be in the range of 300-600 CPZ equivalents (oral or depot) per day.
% not relapsed
(1 yr)
Fluphenazine Decanoate, mg/2 wk
Baldessarini et al. (1988), Arch Gen Psych 45:79-91
Effective Dosage Range:Maintenance Treatment
Schizophrenia PORT
0102030405060708090
100
0 10 20 30 40
Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations
Recommendation 23: Individual and group therapies employing well-specified combinations of support, education, and behavioral and cognitive skills training approaches designed to address the specific deficits of persons with schizophrenia should be offered over time to improve functioning and enhance other targeted problems, such as medication non-compliance.
Cumulative Effect Sizes Adjustment Outcomes
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Intake Year 1 Year 2 Year 3
Personal TherapyVersus No PT
(Begin: N=151) (End: N=125)
N=148 N=151 N=128
From Hogarty et. al. (1996)Year in Treatment
Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations
Recommendation 24: Patients who have on-going contact with their families should be offered a family psychosocial intervention which spans at least nine months and which provides a combination of education about the illness, family support, crisis intervention, and problem solving skills training. Such interventions should also be offered to non-family caregivers.
Combined Therapies for SchizophreniaCombined Therapies for SchizophreniaAnnual Relapse Rates (Hogarty et al., 1986)Annual Relapse Rates (Hogarty et al., 1986)
0%
10%
20%
30%
40%
50%
60%
70%
One Year Two Years
Medications Only
Medications PlusFamilyPsychoeducationMedications PlusSocial Skills
All 3 Treatments
Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations
Recommendation 27: Persons with schizophrenia who have any of the following characteristics should be offered vocational services. The person: a) identifies competitive employment as a personal goal; b) has a history of prior competitive employment; c) has a minimal history of psychiatric hospitalization; d) is judged on the basis of a formal vocational assessment to have good work skills.
VOCATIONAL STUDIESVOCATIONAL STUDIES
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Gervey 94
Bond 95
Drake 96
Chandler 97
Drake 99
McFarlane 00Control
Supported Employment
% Working
Employment Intervention Employment Intervention Demonstration ProjectDemonstration Project
Sponsored by Center for Mental Health Services
A multi-center, longitudinal evaluation of employment interventions for persons with severe mental illness
Randomly assigned and followed for two years.
EIDP TREND # 1EIDP TREND # 1
JOB TENURE SHOWED A TREND TOWARD INCREASED LENGTH OF JOB OVER TIME.
Average Length of Jobs (EIDP, 2001)Average Length of Jobs (EIDP, 2001)
0
50
100
150
200
250
1 Job(N=309)
2 Jobs(N=225)
3 Jobs(N=112)
4 Jobs(N=61)
5 Jobs(N=36)
6 Jobs(N=14)
1st Job
2nd Job
3rd Job
4th Job
5th Job
6th JobAv
era
ge
Len
gth
in D
ays
EIDP TREND #2EIDP TREND #2
TIME BETWEEN JOBS DECREASED OVER TIME
Number of Days Between Jobs Among Number of Days Between Jobs Among EIDP Participants with More than One JobEIDP Participants with More than One Job
57597170
8082
107
0
20
40
60
80
100
120
Between1 & 2
N=416
Between2 & 3
N=221
Between3 & 4
N=119
Between4 & 5N=61
Between5 & 6N=31
Between6 & 7N=18
Between7 & 8N=12
Ave
rag
e N
um
ber
of
Day
s
EIDP TREND # 3EIDP TREND # 3
RECEIPT OF JOB SUPPORT WAS ASSOCIATED WITH LONGER JOB TENURE ON FIRST JOB
DEFINITION OF JOB SUPPORTDEFINITION OF JOB SUPPORT
On-site counseling, support, and problem solving. Providing on-the job help with vocational skills in different work situations and production levels, social skill in the work environment, and job-related skills; may include on-the-job training/assistance.
Mean Length (in days) of First Competitive Job by Receipt of Job Support
Me
an
Le
ng
th in
Day
s
Received Job Support
0
40
80
120
160
No Yes
Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations
Recommendation 29: Systems of care serving persons with schizophrenia who are high service utilizers should include assertive case management and assertive community treatment programs.
CONTROLLED ACT RESEARCHCONTROLLED ACT RESEARCH
17
87 7 7
3 32
6
3
5
1
910
5
7
0
2
4
6
8
10
12
14
16
18
Tim
e in
ho
spit
al
Ho
usi
ng
stab
ilit
y
Qu
alit
y o
fli
fe
Cli
ent
sati
sfac
tio
n
Sym
pto
ms
So
cial
Fu
nct
ion
ing
Vo
cati
on
al
Jail
/arr
ests
Nu
mb
er o
f S
tud
ies
ACT better than Standard
ACT not better than Standard
25 Studies
Inpatient Days: ACT vs. ComparisonInpatient Days: ACT vs. ComparisonLehman et al, 1998Lehman et al, 1998
0500
100015002000250030003500400045005000
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
ACTComparison
Days Homeless on Streets: Days Homeless on Streets: ACT vs. ComparisonACT vs. Comparison
Lehman et al., 1997Lehman et al., 1997
0
500
1000
1500
2000
2500
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
ACTComparison
Outpatient Visits: ACT vs. Outpatient Visits: ACT vs. ComparisonComparison
Lehman et al, 1997Lehman et al, 1997
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
ACTComparison
SCHIZOPHRENIA PORT SCHIZOPHRENIA PORT Current PracticesCurrent Practices
Maintenance dose of antipsychotic within recommended range: 29%
Adjunctive antidepressant: 46%Psychological Interventions: 45%Family psychoeducation: 10%Vocational rehabilitation: 22%
Rates of Conformance with PORT Psychosocial Rates of Conformance with PORT Psychosocial Treatment RecommendationsTreatment Recommendations
APA Office of Quality Improvement and Psychiatric ServicesAPA Office of Quality Improvement and Psychiatric Services
0%10%20%30%40%50%60%70%80%90%
100%C
ase
Man
agem
en
t
Psy
ch
oth
era
py
Fam
ily
Th
erap
y
Vo
c R
eh
ab
An
y
Psy
ch
oso
cia
l
%
of
Patients
0
10
20
30
40
50
60
70
80
90
100
Total IndividualTherapy
Group Therapy Family Therapy
Medicare Claims: 1991Proportion of Study Population with At Least One Visit for Outpatient Service (N=16,480)
Schizophrenia PORT
Major Depression TreatmentMajor Depression Treatment
Acute Phase (Symptom Response_– Placebo……………………... 20-50%– Antidepressant……………. 65-70%– Psychotherapies………….. 47-55%
Maintenance Phase (Relapse Prevention)– Placebo……………………… 15-45%– Antidepressant…………….. 65-79%
Child and adolescent treatments that have Child and adolescent treatments that have been found to be effectivebeen found to be effective
Empirically supported treatments– Cognitive-behavior therapy for childhood anxiety disorders– Cognitive-behavioral coping skills therapy for depression (including school-based
treatments)– Parent management training for disruptive behaviors (including videos for parents)– Problem-solving skills therapy for disruptive behaviors– Social skills training for young children who are aggressive (including school-based
treatments)– Psychotropic medication for Attention Disorders and Obsessive-Compulsive disorders
Empirically promising treatments– Intensive home-based behavior modification for autism– Family therapy for parent-adolescent conflict– Teacher consultation models for disruptive behaviors (reduction in Special Ed. referrals found;
effects on behavior problems unclear)– Psychotropic medication for a number of other symptoms (e.g., depression, anxiety, autistic
behaviors)
Empirically Supported TreatmentsEmpirically Supported Treatments
Conduct Problems Multi-System Treatment
– 84 youth categorized as serious juvenile offenders randomly assigned to MST and standard care through juvenile justice
– After two years, 40% of youth treated with MST avoided re-arrest versus 20% of youth receiving standard care (Henggler, et al 1996)
Behavioral family/parent training – A large average effect size of .86 was found across
studies of family behavioral skills interventions with disruptive behavior disorders (Serketich, Dumas 1996)
Empirically Supported TreatmentsEmpirically Supported Treatments
Depression in Adolescents Cognitive Behavioral Therapy
– Results of large controlled study showed reduction in symptoms in 70% of those treated with CBT
Coping with Depression (CWD) course– 96 youth with major depression randomized to CWD
course or wait-list control– 97.5% of CWD group no longer met criteria for
depression disorder at 2 year follow-up
Pediatric PsychopharmacologyPediatric Psychopharmacology11
Long-termShort-term
C
C
B
B
Bipolar disorders
Aggressive behaviorsLithium
C
C
B
A
Schizophrenia
Tourette’s disorderAntipsychotics
C
C
C
B
Major depression
ADHDTCAs
C
C
C
C
Bipolar disorderAggressive behavior
Valproate &
Carbamazepine
C
C
B
C
Tourette’s disorder
ADHDAdrenergic agonists
C
C
C
B
A
C
Major depression
OCD
Anxiety disorders
SSRIs
BAADHDStimulants
Efficacy2
IndicationClass
1 Jensen, Bhatara, Vitiello, et al 1999 2 A = 2 RCTs; B = 1 RCT; C = clinical consensus
Different Perspectives on OutcomesDifferent Perspectives on Outcomes Example: Utility for Mild Symptoms plus Side Example: Utility for Mild Symptoms plus Side Effects Versus Moderate Symptoms and No Side Effects Versus Moderate Symptoms and No Side
Effects (Lenert et al., 2000)Effects (Lenert et al., 2000)
-0.04
-0.02
0
0.02
0.04
0.06
0.08
0.1
PatientsFamilesProviders
EVOLUTION OF MEDICAL TECHNOLOGY EVOLUTION OF MEDICAL TECHNOLOGY AND COSTS OF TREATING DISEASEAND COSTS OF TREATING DISEASE
(Pardes et al., 1999)(Pardes et al., 1999)
Costs
– palliative treatment cure
• Stages of Technology